Registration Form - Thrive Youth 2023-24

We meet every Friday Night from 7:30 - 10:00PM at Grace Community Church. Check out our website for more details and information on upcoming events:

https://gracewinnipeg.ca/youth/

*Parents/Legal Guardians registering a child for a special event will be expected to complete a special event form in addition to this one.

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

Parent/Guardian Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent's Email*

Parent's Email

example@example.com

Would you like to be added to the Thrive email list?*

YesNo

Parent Guardian Daytime Ph #*

Area CodePhone Number

In case of an emergency we would contact the names/numbers listed above first. Please provide an alternate name and number if you can’t be reached.

Alternate Name*

First NameLast Name

Alternate Ph #*

Area CodePhone Number

Relationship to child*

In the case of custody agreements, please submit the proper form authorizing parental contacts.

Provincial Health Insurance Number of Student 9 digit*

Provincial Health Insurance Number of Student 6 digit*

Family Doctor*

Does your child have any allergies?*

NoYesOther

Does your child have any physical, emotional, mental, behavioural limitations that our staff should be aware of?*

NoYesOther

Does your child take any regular medication that we should be aware of? *

NoYesOther

Medical Consent

The safety of your child is our primary concern. Precautions will be taken for their wellbeing and protection. I/we, the parents or legal guardians named on this form, authorize Grace Community Church’s Staff or Ministry Personnel to call Emergency Medical Services (911), sign a consent for emergency medical treatment and to authorize any physician or hospital to provide emergency medical assessment, treatment or procedures for the participant named on this form. Any costs incurred will be the responsibility of the parent/legal guardian. I/we, named on this form, undertake and agree to indemnify and hold blameless the Staff of Grace Community Church, its Ministry Personnel and Board of Deacons from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Grace Community Church, as well as of any emergency medical treatment authorized by the supervising individuals representing Grace Community Church. This consent and authorization is effective only when participating in or traveling to and/or from events of Grace Community Church. Do you agree with the terms above?*

Yes

Do you grant permission for future reasonable & safe use of pictures/video containing your child in the following ways: brochures/promotional material , displays/crafts, Grace Community Church website and/or newsletters?*

NoYes

Purposes and Extent
Grace Community Church is collecting and retaining this personal information for the purpose of enrolling your child in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities in our programs. The information you have provided shall be treated as confidential and will only be revealed on an as needed basis. This information will be maintained indefinitely. If you wish Grace Community Church to limit the information collected, or to view your child’s information, please contact us.

Parent/Guardian Signature*

GRACE COMMUNITY CHURCH - Annual Registration Form, THRIVE YOUTH 2023-24